A nurse is assessing a 1-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?

Limited hip abduction

Equal leg length

Symmetric gluteal and thigh skin folds

Femoral head remains in the acetabulum during the Barlow maneuver

Answer and Explanation

The Correct Answer is A

Rationale:

A. Limited hip abduction: Limited abduction of the hips in a 1-month-old can indicate developmental dysplasia of the hip (DDH). This finding warrants further evaluation, such as ultrasound imaging, to rule out structural abnormalities and initiate early treatment if needed.

B. Equal leg length: Equal leg length is a normal finding and does not require intervention. Leg length discrepancies are more concerning and often associated with hip dislocation or other musculoskeletal conditions.

C. Symmetric gluteal and thigh skin folds: Symmetry in the gluteal and thigh folds is a reassuring sign that typically rules out DDH. Asymmetry would be more suggestive of a hip abnormality requiring follow-up.

D. Femoral head remains in the acetabulum during the Barlow maneuver: This is a normal finding. The Barlow test assesses for hip instability, and if the femoral head remains stable within the socket, no further evaluation is needed.

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Free Nursing Study Resources

Correct Answer is ["B","C","D"]

Explanation

Rationale:

Client has initiated a daily exercise routine: This indicates self-motivation, structured routine, and engagement in positive coping behaviors, all of which are therapeutic goals in managing schizophrenia.
Client utilizes deep breathing techniques as needed: Use of self-regulation techniques like deep breathing suggests the client is managing anxiety and stress proactively.
Client has joined a local support group: Participation in social support groups improves social functioning and decreases isolation, a common issue in schizophrenia.
Client has been reading books about their illness: Demonstrates insight, knowledge-seeking behavior, and a willingness to understand and manage the condition, which aligns with psychoeducation goals.
Client participates in cognitive-behavioral therapy sessions with their mental health provider: Engagement in CBT is a strong indicator of therapeutic alliance and compliance with structured treatment plans aimed at cognitive restructuring and behavioral management.

Rationale for Incorrect Finding:

Client reports spending most of their time alone in their apartment: Although some solitude is not unusual, spending most of the time alone may indicate ongoing social withdrawal, a negative symptom of schizophrenia, and a barrier to full community reintegration.
Client reports drinking 4 to 5 cups of coffee each morning: Excessive caffeine can worsen anxiety, interfere with sleep, and interact with psychiatric medications, so this behavior does not align with optimal treatment outcomes.

A. Palpate the client's bladder in 1 hour. B. Place the client's hands in a bowl of cold water. C. Have the client listen to running water while on the toilet. D. Perform effleurage over the client's lower abdomen.

Correct Answer is C

Explanation

Rationale:

A. Palpate the client's bladder in 1 hour: Waiting another hour to assess the bladder delays intervention. At 10 hours postpartum with no void, immediate action is needed to stimulate voiding or assess for urinary retention.

B. Place the client's hands in a bowl of cold water: This technique is more commonly used in children and is less effective in stimulating voiding in postpartum adults. It is not a first-line strategy in this context.

C. Have the client listen to running water while on the toilet: This is a noninvasive and effective method to stimulate the urge to void by triggering the micturition reflex. It can help relax pelvic muscles and encourage urination postpartum.

D. Perform effleurage over the client's lower abdomen: Effleurage is a light massage technique used primarily for labor pain management. It is not a recognized or effective method to promote urination in postpartum care.

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A nurse is assessing a 1-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","D"]

Explanation

A nurse is caring for a client who has not voided since giving birth vaginally 10 hours ago. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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